Manpower cost for a hypertension health campaign: A cross-sectional study

Abstract Introduction: The overall prevalence of hypertension is high, and many people are unaware of their condition. Screening campaigns can effectively identify this group of patients. The study aimed to determine the cost of manpower for a health campaign for detecting undiagnosed hypertension and the prevalence of hypertension. Method: This cross-sectional study was conducted at two health centres. Sociodemographic characteristics, hypertension and treatment statuses were recorded. Blood pressure (BP) was measured by either doctors or nurses using automated BP machines. The cost of manpower was calculated as the average salaries of manpower during the 3-day health campaign divided by the total number of days. The final sum was the cost of detecting undiagnosed hypertension. Results: A total of 2009 participants median age = 50 (IQR = 18-91) were included in the study. The overall prevalence of hypertension was 41.4% (n=832). Among the patients with hypertension, 49.2% (n=409) were unaware of their hypertension status. Conversely, 21.1% (n=423) were known to have hypertension, among whom 97.4% (n=412) were on medications. Among those who were on medications, 49% (n=202) had good BP control. The average total cost of manpower during the 3-day health campaign was RM 5019.80 (USD 1059). The cost of detecting an individual with elevated BP was RM 12.27 (USD 2.59). Conclusion: The prevalence of hypertension and unawareness is high. However, the average cost of manpower to detect an individual with elevated BP is low. Therefore, regular public health campaigns aiming to detect undiagnosed hypertension are recommended.


Introduction
e global prevalence of hypertension is high.According to the Global Burden of Disease Study, hypertension is the leading preventable cause of death and the third leading cause of disability. 1 Most cardiovascular morbidity and mortality are attributed to undiagnosed hypertension. 2In developing countries, 71.8% of individuals are unaware that they have elevated blood pressure (BP). 3Despite the availability of e cacious therapeutic agents, many patients with elevated BP do not take antihypertensive medications.Much of this is attributed to unawareness of the presence of elevated BP.4 e National Health and Morbidity Survey 2019 conducted in Malaysia showed that the overall prevalence of hypertension among adults aged ≥18 years was 30%, while that of unawareness of the condition was 47%. 4 In 2022, the World Health Organization's Global HEARTS Initiative and the HEARTS in the Americas Initiative were implemented to catalyse the application of the latest guidelines in prioritising the prevention and control of hypertension to improve patients' well-being and reduce cardiovascular complications. 5Prevention is better than cure, but this comes with a cost.
e costs associated with healthcare continue to be a major concern worldwide.In Malaysia, the primary healthcare treatment or rst-line treatment in public healthcare settings, including blood tests, bio-imaging and medications, incurs a fee ranging from RM 1 to RM 5 per visit.Conversely, the costs of accessing similar services at private clinics/hospitals are regulated by the Private Healthcare Facilities and Services Amendment Order 2013. 6Initial general and specialist consultations cost RM 30-125 and RM 80-235, respectively. 6Such costs could be nancially distressing to certain groups of the population, especially those with a lower socioeconomic status.In Malaysia, there are many strategies and recommendations that can be applied to overcome this problem.One of them includes a general health campaign that aims to provide free screening and counselling to the public and the community.
e Health Care Scheme for the B40 group (bottom 40 according to the Malaysian household income classi cation) is a government initiative implemented by the Ministry of Health that aims to sustain the healthcare needs of low-income groups by focusing on screening of non-communicable diseases. 7present study aimed to determine the prevalence of unawareness of elevated BP and calculate the cost of manpower for detecting undiagnosed hypertension.Further, the prevalence of known hypertension, status of antihypertensive medication or treatment and hypertension control were evaluated.

Methods
In this cross-sectional study, a hypertension health campaign was conducted in conjunction with World Hypertension Day at two separate centres (one teaching hospital and one public health clinic).e campaign was conducted for 3 days.Individuals aged ≥18 years who were visiting the health facilities were included, while those who were pregnant were excluded.Verbal consent was obtained.
ereafter, the participants were asked a few simple questions regarding their sociodemographic data and hypertension and treatment statuses.e participants' BP was measured by either doctors or nurses using automated digital BP devices in accordance with the Malaysian Clinical Practice Guidelines (CPGs) on the Management of Hypertension. 8 participants were seated for 1 min before commencement of the BP measurements.
e BP was measured twice with a 1-min interval, and the average of the two readings was calculated.We used a standard bladder that encircled at least 80% of the arm circumference, with the width encircling at least 40%.
e cu was placed at the heart level.Hypertension was de ned as a BP of ≥140/90 mmHg. 9Hypertension was considered controlled when the BP was <140/90 mmHg, as recommended in the CPGs on the Management of Hypertension. 8participants who had elevated BP were directed to doctors' station where their BP was measured again using a mercury sphygmomanometer via the above-mentioned method.With the auscultatory method, we used phase I and V (disappearance) Korotko sounds to identify systolic and diastolic BP, respectively.e BP reading with the higher value was used as the reference.
All participants were given information on healthy lifestyles regardless of their BP readings.e participants who were found to have elevated BP were counselled and given speci c instructions to consult their family doctor or return to our clinic for con rmation of their hypertension status.We also provided them with a small advice paper with their BP reading to ease the process of follow-up.

Cost calculation
e cost of manpower was calculated as the sum of the average salary of a doctor per month divided by 22 working days multiplied by four doctors multiplied by 3 days and average salary of a nurse per month divided by 22 working days multiplied by four nurses multiplied by 3 days.e total sum of both salaries was divided by 409 individuals who were not known to have hypertension but had high BP.e detail of the formula was shown in table 3.

Statistical analysis
Data were statistically analysed using the Statistical Package for the Social Sciences (version 23).Continuous data that were normally distributed such as systolic BP and diastolic BP were described as means and standard deviations while age was described as median and range as it was not normally distributed.Categorical data, including independent variables such as sex, race, hypertension status, treatment status and hypertension control, were reported as frequencies (percentages).All data were fully presented without restriction.

Results
A total of 2009 participants were included in the study.e median age of the participants was 50 with interquartile range (IQR) =18-91 years.Half were women (50.5%, n=1015).
e majority of the participants were Malay (56.3%, n=1132), followed by Chinese (24%, n=483), Indian (16.8%, n=337) and others (2.8, n=57).e prevalence of known hypertension was 21.1% (n=423) (Table 1 SBP, systolic blood pressure; DBP, diastolic blood pressure; SD, standard deviation; IQR, interquartile range e total prevalence of hypertension was 41.4% (n=832).Among the participants with hypertension, the total prevalence of unawareness of the condition was 49.2% (n=409).Among those who were known to have hypertension, 97.4% (n=412) were on antihypertensive medications.Among those who were on antihypertensive medications, 49% (n=202) had good BP control (Table 2).BP, blood pressure *Unaware of their hypertension status=total prevalence of unawareness e average salary of a doctor was RM 5302.98, while that of a nurse was RM 3900.e average salary was divided by the number of working days (22 working days in a month, excluding four weekends).e total salary of four doctors and four nurses for the 3-day health campaign was RM 5019.80 (RM 2892.53 for the doctors and RM 2127.27 for the nurses).e number of participants who were unaware of having elevated BP was 409.Accordingly, only RM 12.27 (USD 2.59) was calculated to be required to detect one person who was unaware of having elevated BP (Table 3).

Discussion
][12][13] E orts to reduce this major risk factor are hampered by the high prevalence of unawareness, and hence, opportunities to treat and reduce the BP and cardiovascular risk are missed.Our study showed that the prevalence of unawareness of the presence of hypertension was 49.2%, compared with 47% reported in the National Health and Morbidity Survey 2019. 35] As the prevalence of unawareness of elevated BP is high, many health authorities have invested in public health education and campaigns to raise awareness.Apart from these educational e orts, adopting a di erent strategy such as actively and regularly organising health campaigns is recommended.However, such an approach would require an increase in overall cost.
In our study, we found that the cost of manpower for detecting an individual who was unaware of having elevated BP was relatively low at RM 12.27 (USD 2.59).In view of such low cost, it is worthwhile to organise regular health campaigns to increase the level of awareness up to 80% as reported in some developed high-income countries such as the USA 16 and some Asian countries. 17f the level of awareness is increased, individuals with elevated BP can receive appropriate management as early as possible.
e advantages of health campaigns include counselling individuals on their BP status and providing advice on the bene ts of healthy lifestyle changes, which could be achieved simultaneously without incurring additional costs.Studies have also shown that the advices given by doctors at the time of diagnosis have the greatest impact on behavioural changes. 18For example, better BP control can be achieved if patients have known cases of diabetes and chronic kidney diseases. 19Modi able risk factors such as higher body mass index, imbalanced diet especially excessive sodium intake, smoking and excessive alcohol consumption can lead to poor control of hypertension.1] In this study, advices were also given during the health campaign by the attending doctors and nurses with no added cost.Another bene t of our health campaign was that the patients who were unaware of having elevated BP were advised to have a complete medical checkup to reduce the overall risk of cardiovascular events, while those with normal BP were advised to have an annual BP checkup to detect and treat any abnormal BP changes early.A study conducted in Canada found that older patients reported 3.02 fewer annual hospital admissions for cardiovascular disease in the intervention group than in the no screening group. 22A systematic review concluded that it is important to con rm the diagnosis of hypertension by applying re-screening intervals and conducting home pressure monitoring following a screening programme. 22 study demonstrates the cost-e ectiveness of identifying individuals with elevated BP who are unaware of their condition through public health campaigns for hypertension.It is hoped that this nding will encourage more healthcare centres and providers to organise such health campaigns.Accordingly, more individuals who are not aware of their hypertension status can be identi ed, and the condition can be treated in its early stage.Subsequently, the cardiovascular risks attributed to undiagnosed or poorly controlled hypertension can be reduced.However, when discussing the overall coste ectiveness of managing hypertension, factors such as doctors' hesitancy to initiate treatment for patients who are newly diagnosed with hypertension or those who have poorly controlled BP, patients' adherence to lifestyle changes and medications and the adequacy of supply of antihypertensive agents in healthcare centres should be taken into consideration.In a previous study, it was shown that a community health screening campaign for hypertension that involved education and referral had achieved an excellent linkage to further care and management. 23 summary, health campaigns including screenings can be implemented by health authorities, particularly at healthcare centres where many people frequently visit such places.
e additional cost incurred is minimal, as all necessary sta and screening facilities are already readily available and in place.
is should make such campaigns highly a ordable, even in low-resource countries where the prevalence of elevated BP and unawareness of such is increasing along with changes in lifestyle.Health campaigns should be promoted vigorously through the development and implementation of national action plans provided the country is ready to follow up and treat this group of patients.However, it is essential to consider the potential in ux of patients newly diagnosed with hypertension who will require long-term follow-up and treatment in the future.erefore, a well-structured and planned algorithm must be created and implemented to prevent overwhelming the healthcare system.Government and non-government organisations must also enhance their contributions to hypertension screening or health campaigns, enabling national health authorities to implement various strategies aimed at reducing the prevalence of hypertension and increasing the awareness level and treatment rate among patients with hypertension.Additional studies are necessary to determine the cost-e ectiveness of screening or health campaigns in other scenarios.Further cost-e ectiveness studies on the cost of emergency admissions and treatments of complications resulting from unawareness of hypertension could help emphasise the need for screening.

Limitations
e prevalence of hypertension observed in our study might not be generalisable to the whole community, as the health campaign was conducted in selected healthcare centres.
e participants were also recruited via convenience sampling: ose who were interested and presented themselves at our campaign were screened.Further, the average salary of a doctor and a nurse may di er according to their grade and position.We also did not include the potential cost of space/rental and electricity, as these are already available in the healthcare centres.A full analysis of cost-e ectiveness could be more complex, as other healthcare costs such as those of unscheduled emergency visits, hospitalisations and treatments of complications of uncontrolled hypertension would need to be considered.

Conclusion e prevalence of hypertension and unawareness remains high.
e cost of manpower for identifying one person who is unaware of having elevated BP is relatively low at only RM 12.27 (USD 2.59).With the high level of unawareness and low cost of detecting an individual with hypertension, it is encouraging to hold health campaigns to detect undiagnosed hypertension in the community.Further studies that would conduct thorough cost-e ectiveness analyses based on the BP detection rates and costs attributed to cardiovascular morbidity and mortality are needed.

How does this paper make a di erence in general practice?
• In Klang Valley, there are few health campaigns available, and the response of healthcare centres in organising a health campaign is poor.• Organising a health campaign is bene cial to patients owing to the low cost.
• Awareness of healthy lifestyles, including the Dietary Approaches to Stop Hypertension diet, can be instilled to the public through a hypertension health campaign.• e study was able to conduct screening using existing trained sta and infrastructures without incurring additional costs.

Table 2 .
Awareness and status of treatment and control among the adults with hypertension.

Table 3 .
Cost calculation for detecting an individual who was unaware of having elevated BP.